property needs - west lothian information in this property needs assessment form is ... • nervous...
TRANSCRIPT
Property Needs
Only to be completed if you are having difficulty managing in your current property due to your medical condition.
FOR OFFICIAL USE ONLY
Applicants name:
Date received:
Received by:
Date passed to Central Allocations:
Date received by Central Allocations:
Reference no:
Time received:
GUIDANCE NOTES
The information in this Property Needs Assessment form is required to enable the West Lothian Housing Register to assess your health needs and how they relate to your application for housing. Please answer all questions that relate to you in your own words.
Please note, to be eligible to apply for a Property Needs Assessment due to physical or mental health impairment, applicants must meet the following criteria:
• An applicant must be in the current case load of a mental health professional (Psychiartist/Psychologist/Community Psychiatric Nurse/Social Worker in Mental Health Team) or meeting with their General Practitioner who is offering psychological therapies to address mental illness. There must be confirmation from the practitioner that in their professional opinion a significant improvement in their mental health is likely as a result of re-housing, and that the mental health is not expected to resolve using other treatments alone.
• Chronic conditions whereby the housing environment exacerbates the condition will be looked at on an individual basis. Further information may be sought.
Please note that NO medical priority will be given for any of the following:MEDICAL CONDITIONS
SOCIAL CONDITIONS
Please note, the West Lothian Housing Register aims to assist applicants:
• Where it is demonstrated that an applicant requires an adaptation which will meet their needs and allow them to remain in their current accommodation.
Through this process the West Lothian Housing Register aims to assist applicants that have a need to either move to a property that is better suited to their needs or to ensure that their existing property meets their needs as a result of the installation of adaptations or provisions.
PLEASE ANSWER ALL QUESTIONS IN BLOCK CAPITALS
If applying for any of the following reasons, these criteria must be met:Epilepsy/SeizuresThe applicant is under the care of a named Specialist Nurse in epilepsy and/or a Consultant Neurologist. In the opinion of the Specialist, any drug treatment has been optimised. The applicant’s home contains a flight of six or more stairs and it is unsafe for the applicant to negotiate these stairs without supervision. Points will not be awarded to an applicant because they consider that the rooms in the house are small.
Note: Epilepsy/Seizures of this sort is inconsistent with the person holding a driving licence or being able to walk near heavy traffic without being accompanied.
AsthmaThe applicant must be under the care of a Physician specialising in Respiratory Disorders and/or in Allergic Disorders. The applicant must be compliant with treatment and that treatment must be optimised. The Specialist will need to clarify why the property is unsuitable.
• Nervous debility or breakdown• Growing pains• Glue ear, grommets, middle ear
infection • Skin problems or disease• Bronchitis or chesty cough• Duodenal or gastric ulcers
• Temporary orthopaedic problems such as broken bones or sprains
• Glandular fever • Hernia or rupture Epilepsy
controlled by medication• Bedwetting or enuresis
• Obesity or being overweight• Hiatus hernia• Sexually transmitted diseases
(excluding HIV )• Any temporary illness including
Varicose veins
• Central heating priority • Overcrowding• Pregnancy • Under occupancy• Problems with neighbours• Harassment
• Whether or not you have a garden
• Homelessness• Being a single parent• Living with relatives• Illness of relatives
• Marital or relationship problems
• Problems with the structure of your home - no bath, type of windows or heating
• Dampness
PROPERTY NEEDS ASSESSMENT FORM
1. Housing applicant
Name .................................................................................................................................................................................................................................
Address ............................................................................................................................................................................................................................
................................................................................................................................................................. Post Code ......................................................
Date of Birth ................................................................... Tel No ...........................................................................................................................
2. Person in household seeking assessment (if different from above)
Name .................................................................................................................................................................................................................................
Address ............................................................................................................................................................................................................................
................................................................................................................................................................. Post Code ......................................................
Date of Birth ................................................................... Tel No ...........................................................................................................................
Why was this assistance required? ........................................................................................................................................................
.....................................................................................................................................................................................................................................................
3. Relationship to applicant
................................................................................................................................................................................................................................................... MEDICAL PROBLEM / DISABILITY
Mr, Mrs, Miss, Ms ............................ Name ................................................................................................
Address ......................................................................................................................................................................
................................................................................................... Postcode ..............................................................
Tel No .................................................................................. Relationship to you ........................................
Why was this assistance required? ........................................................................................................
...........................................................................................................................................................................................
4. If someone assisted you with this form, please tell us who they were
5. Please describe the medical condition and/or disability ......................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................................
Medication – Please list your medication here: .............................................................................................................................
...................................................................................................................................................................................................................................................
PROPERTY NEEDS ASSESSMENT FORM
5a. How does your present home/home environment affect the medical condition/disability?
..............................................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................................
5b. Please tell us how you are able to carry out the following activities (please tick)
TASK INDEPENDENT ABLE WITH HELP DEPENDENT
Personal Care e.g. Bathing/Eating/Dressing/Toileting
Managing your tenancy e.g. Shopping/Cooking/ Cleaning/Managing finances
Community Involvement/Socialisation e.g. Hobbies/Socialising/Accessing Community
6a. Within the last year have you had an Occupational Therapist/Social Work/
Mental Health assessment carried out?
Yes No
If yes, please provide contact details of the person who carried out the assessment:
....................................................................................................................................................................................................................................................
......................................................................................................................................................................................................................................................
6b. Please advise of your GP’s name and address and that of any other health/social work professionals and/or support workers with whom you have had recent contact. (We may need to contact them.)PERSON’S NAME AND PROFESSION
ORGANISATION’S ADDRESS AND PHONE NUMBER
WHEN DID YOU LAST SEE THEM?
HOW OFTEN DO YOU MEET WITH THEM?
HOW DO THEY SUPPORT YOUR CONDITION/DISABILITY.
PROPERTY NEEDS ASSESSMENT FORM
YOUR CURRENT PROPERTY
7a. Tenure type
Council/Housing Association Tenant Owner
Private Tenant Other (please specify)
..........................................................................................
7b. What type of property do you live in?
House Flat 4-in-a-block (communal access)
Sheltered housing Supported housing 4-in-a-block (own access)
Maisonette Bungalow Wheelchair Accessible Property
8. What floor is your property on?
Ground floor 1st Floor 2nd Floor 3rd Floor 4th and over
Please list which rooms are upstairs or downstairs ....................................................................................................................
.......................................................................................................................................................................................................................................................
PLEASE ONLY ANSWER QUESTIONS 9 - 16 IF YOU HAVE A PHYSICAL HEALTH DIFFICULTY OR HAVE ISSUES WITH MOBILITY.
9. How many external stairs are there to your property from the public footpath?
10a. How many stairs are there inside your property?
10b. If there are communal stairs, how many?
11. Are the internal stairs?
Straight Turn Short flights with a landing between Other
12. Has your current home been adapted? Please tick the following:
Wet floor shower / level Stairlift Fixed ramp
Ground floor bedroom Ground floor WC Through floor lift
Tracking hoist
PROPERTY NEEDS ASSESSMENT FORM
MOBILITY
13a. Do you use walking equipment? Yes No
13b. What type of walking equipment do you use? ..........................................................................................
.......................................................................................................................................................................................................................................................
14. Do you use an electric wheelchair/scooter? Yes No
Who provided/purchased this equipment? ......................................................................................................................................
Where is it used? Inside Outside
What are the dimensions of the wheelchair? ..............................................................................................................................
15. Is your current home wheelchair accessible? Yes No
16. How many stairs can you climb?
None One or two
One flight (average 14 stairs) More than one flight of stairs
DECLARATIONI agree that in accordance with the terms of its registration under the Data Protection Act 1998, the Partner Landlords of the West Lothian Housing Register may use the information I have supplied. I consent that my doctor, hospital consultant, health visitor, social worker or any other relevant person can be contacted if more information is needed for my Property Needs Assessment application.
Print Name ....................................................................................................................................................................................................................
Signature .........................................................................................................................................................................................................................
Date .......................................................................................................................................................................................................................................
FAILURE TO SIGN THIS DECLARATION WILL RESULT IN THE FORM BEING
RETURNED TO YOU AND WILL DELAY YOUR ASSESSMENT
